MCC of VA (HMO SNP) covers Medicare Part D prescription drugs. There is no annual deductible and no premium. However, depending on the level of “extra help” you get from Medicaid to pay for your Part D medications, you may pay copays for certain drugs.
Copays for generic and preferred multisource drugs are $0, $1.30, or $3.60 per prescription. All other drugs are $0, $3.90, or $8.95 per prescription.
Our formulary is a list of covered drugs your provider may prescribe to you. It’s developed with a team of health care providers and includes prescription drug therapies believed to be a necessary part of a quality treatment program. MCC of VA (HMO SNP) generally covers the drugs listed in the formulary as long as:
- The drug is medically necessary
- The prescription is filled at a network pharmacy
- Other plan rules are followed
Some of the drugs in our formulary have certain restrictions. Restrictions may include:
- Prior authorization
- Quantity limits
- Step therapy
What is prior authorization?
Some drugs require approval from MCC of VA (HMO SNP) before they can be filled; this is called a coverage determination. If you don’t get approval, your drug may not be covered. The drugs on the lists below require prior authorization:
What are quantity limits?
We limit the quantities of certain drugs that you may fill within a given timeframe.
What is step therapy?
You may need to first try certain drugs to treat your medical condition before we will cover another drug for that same condition. For example, if Drug A and Drug B both treat a member’s medical condition, MCC of AZ (HMO SNP) may not cover Drug B unless the member tries Drug A first. If Drug A does not work, we will then cover Drug B. You can see that list of drugs here.
What if I need a drug that isn’t on the drug list or has restrictions?
If you or your doctor believe you need a drug that is not listed on our formulary (or list of covered drugs), you need to request prior authorization or you’d like us to remove a limit or restriction, you or your provider may ask for an exception or Part D coverage determination. For more information, read our Coverage Decisions, Appeals and Grievances page.
Medication Therapy Management (MTM Program)
Medication Therapy Management (MTM) is a program for members with complex medical conditions. The program helps you to safely manage your medications.
If you have at least three (3) chronic conditions and take at least seven (7) long-term drugs that cost more than $4,255 per year, you may be eligible. The program is not considered a benefit and is free to all members. You’re not required to participate, but we encourage you to.
If you qualify for the program, we’ll send you a letter with more information about the program. If you join, a pharmacist will meet with you to go over all your prescription drugs and give you a Comprehensive Medication Review (CMR). The pharmacist will look at how your medications work together and may suggest ways to make it easier for you to take them. You’ll get a Personal Medication List (PML) with instructions you can share with your doctors and caregivers. The appointment should last about 20 minutes.
As part of the CMR, the pharmacist may also help you with specific drug-related issues, called a Targeted Medication Review (TMR). The TMR will identify any drug therapy issues and may recommend alternatives to your provider. If you are unable to travel to a pharmacy, contact Member Services to schedule a telephone medication review with a pharmacist.
You can ask your pharmacist if he or she is an OutcomesMTM pharmacist. OutcomesMTM works with Magellan Complete Care of Virginia (HMO SNP) to provide this service. If your pharmacy doesn’t participate or you want to speak to another pharmacist, please call Member Services at 1-800-424-4495 (TTY 711) from 8 a.m. to 8 p.m., Monday through Friday. If you choose another pharmacy for this service, you can still continue to fill your prescriptions at the pharmacy you currently use.
*Qualifying chronic conditions include: Rheumatoid arthritis, arthritis, chronic heart failure (CHF), diabetes, dyslipidemia, hypertension, chronic lung disorder, chronic obstructive pulmonary disease (COPD).
In certain situations, you may be able to get a temporary supply of medication that is either not on our drug list (formulary) or is subject to certain restrictions, such as prior authorization or step therapy. This applies to:
- New MCC of VA (HMO SNP) members within the first 90 days of membership
- Current MCC of VA (HMO SNP) members affected by a drug list change from one year to the next within the first 90 days of the new plan year
If this happens, you should talk to your doctor to decide if you should switch to another drug on our formulary or request a formulary exception. Current members may request an exception in advance for the following year.
During this period of transition, we will automatically process a refill (up to a 30-day supply or less if the prescription is written for fewer days). Once we cover the temporary supply, we generally will not pay for these drugs again as part of our transition policy. We’ll send you a written notice explaining the steps you can take to request an exception and how to work with your doctor to decide if you should switch to another drug on our formulary.
Following your exception request, we’ll make a decision to either approve or deny the request. In many cases, where it is clinically appropriate, we may approve the continued use of an important drug that you’ve been stabilized on. In those situations, you will receive an approval letter.
If you’re a new member who is a resident of a long-term care facility, we’ll cover a temporary 30-day transition supply (unless the prescription is written for fewer days). If necessary, we will cover more than one refill during the first 90 days of membership. If you’ve been enrolled in the plan for more than 90 days and need a drug that isn’t on our drug list or is subject to other restrictions such as step therapy or dosage limits, we will cover a temporary 31-day emergency supply of that drug (unless the prescription is for fewer days) while you’re pursuing a drug list exception.
Please note: We will use multiple approaches to ease the transition of new members who may be on drugs that are not part of our drug benefit or have other restrictions associated with them. This policy specifically applies to non-formulary drugs, and drugs requiring step therapy, prior authorization or other rules that would limit the immediate access to or continuation of an existing drug therapy by a new member.
Best Available Evidence
If you believe you qualify for Extra Help or the low-income subsidy (LIS), and you are paying an incorrect cost-share amount for your prescriptions, please contact Member Services. We use Medicare’s Best Available Evidence policy to determine the amount you pay.